Healthcare Provider Details

I. General information

NPI: 1811906241
Provider Name (Legal Business Name): ADOLESCENT & FAMILY COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S MAIN ST THE REPUBLIC BUILDING / SUITE 23
CHESHIRE CT
06410-3160
US

IV. Provider business mailing address

350 S MAIN ST THE REPUBLIC BUILDING / SUITE 23
CHESHIRE CT
06410-3160
US

V. Phone/Fax

Practice location:
  • Phone: 203-271-1234
  • Fax: 203-272-9094
Mailing address:
  • Phone: 203-271-1234
  • Fax: 203-272-9094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCT

VIII. Authorized Official

Name: MR. HERBERT JAY ROSENFIELD
Title or Position: DIRECTOR
Credential: ACSW, LCSW, BCD
Phone: 203-271-1234